Healthcare Provider Details

I. General information

NPI: 1598659112
Provider Name (Legal Business Name): ANTHONY OTIS MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 CLAIBORNE SQ E STE 334
HAMPTON VA
23666-2074
US

IV. Provider business mailing address

2822 PICKETT RD APT 154
DURHAM NC
27705-9307
US

V. Phone/Fax

Practice location:
  • Phone: 757-713-1296
  • Fax:
Mailing address:
  • Phone: 757-713-1296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904006260
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: